Provider Demographics
NPI:1992351662
Name:ANDERSON, KENNETH A JR (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:
Practice Address - Street 1:700 E MOREHEAD ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2742
Practice Address - Country:US
Practice Address - Phone:704-334-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011442363A00000X
NC0010-12054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant